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Monday
Sep202010

Blog Carnival: Midwifery & Racism

Pamela Hines (Midwife: Sage Femme, Hebamme, Comadrona, Partera) and I were commenting in Facebook the other day about Midwives of Color when I asked:

"Why is this segment of midwifery invisible to me? (My own [unrealized] bigotry?)"

A short discussion ensued about white privilege, how midwifery is so incredibly expensive to pursue and how it would be great to hear more thoughts about this topic. Pamela said she'd been thinking about a Blog Carnival, too, so here, I ask:

Who's game?

Shall we set a date of September 30 for the date of posting?

Please pass this around and let's write, shall we?

Thursday
Mar272008

Kneelingwoman's Post

So, I try to be eloquent, but sometimes another blogger puts what I want to say so perfectly, I am almost embarrassed that I tried to stutter the words at all.

Kneelingwoman - Michelle - wrote a post that got eaten the other day, but, happily, she re-wrote the entire long piece. (We told her to write in Word!)

Please, please go read the entire post - Back to the Garden. No matter your stance on midwifery education, you are sure to be reminded of - or learn - something that will impact your calling/profession immediately.

Excerpts (and I did take a lot of her words, but there are more... wonderful words on her blog. Please go read them):

- We are a fractured profession with relationships constructed around a false front of unity in a central theme; but not of a shared reality.

- ...I see Midwifery taking on the dynamics of a highly dysfunctional family. Midwives who "color outside the lines" or who fail, in some way, to ensure that "outsiders" don't know "our" business; are threatened, bullied, maligned, blacklisted or, in some other way, isolated and rejected by their peers. Just as in family systems where whole lives are lived in closely guarded spaces of secrecy and anger and the one who begins to tell the truth becomes the scapegoat; so it often is in Midwifery. In an ironic twist; all of these things are fueled by fear and, as all Midwives know, fear is the enemy of birth--of a person, an idea or a profession.

- moving to another letter written to me by someone in the Midwifery leadership a week or so ago that tells me that "the BMJ study proves that more education doesn't improve outcomes" and "I don't see that CNM's have any more economic security; a lot of them are losing their jobs so I don't see how a University education of the kind you're proposing insures anything". Sighing deeply, I respond that I hadn't thought that the BMJ was designed to prove that contention and therefore, can't. I comment that a CNM, as a Registered Nurse, is still very employable, with a well paying credential as a Nurse even if she can't, regretably, find a job as a Midwife. A direct entry midwife, in contrast, may have nothing else, no other education or training, with which to make a living. I think that's a very big problem and I find it very concerning that the people in "leadership" positions in Midwifery can make such unsupportable comments or fail to see the connection between a broader, more diverse education and a more viable and sustainable, Profession.

- We need a midwifery that is cooperative and accountable to the other health care professions with whom we MUST collaborate and work alongside to ensure safe practice!

- The fear that drives the rejection of examining new models or promotes a rigid clinging to concepts of "apprenticeship" and "woman centered care"as sacred cows; or the idea that altering our education to meet new needs and desires takes something away from midwifery, is preventing the labor from bringing something to birth! We are a "post dates" pregnancy holding off any intervention until there are no more choices left. That is not wise. That is not being "with women". It is telling the women--the vast majority of women, that what matters in midwifery is the midwives alone; our comfort level and our standards. It seems, and is, inflexible and exclusive; not diverse or expansive.

- Midwives have to stop fearing that our inner-workings can't bear the scrutiny of physicians, legislators or the public. Sending up a warning flare or browbeating midwives who speak to these issues into submission and retraction does not solve a problem related to how we are perceived by those who will, in large part, determine our future. We have to remain transparent and open and accept criticism if needs be. We may need to change the way we do some things if we want to grow and remain viable. We should not fear hearing those criticisms nor should we attempt to restrict those who think we really need to take a second look at how we're doing things. We cannot continue to practice in isolation from the rest of the health care system while insisting that they include us! Midwifery is not an island and it most certainly is not some maternal paradise where all women are safe and welcome! For many women, mothers and practioners alike; midwifery becomes a place of uncertainty, financial and social insecurity and professional stagnation! That is not a sustainable vision; these are the marks of an unsustainable profession that won't get serious about examining it's preconceptions and conclusions to see if they work over time.

- We have gone overboard in telling women to trust their bodies and birth and we have not done a good job educating women about the inherent wildness and unpredictablity of birth. We seem to not know how to backtrack on this position without risking a wholesale return to the idea of allowing fear to dominate women's thinking about birth and the resultant potential "loss" of midwifery clientele. My response to this is, very clearly, "we have to find a way" because babies are dying and women are suffering because they are not taking any risks into account when they plan these births.

- I feel like the woman 'stuck' at 8 cm's who has moved every way she can; changed positions over and over, moaned and rocked and, now, reaches out for the hand of her midwife, her mate, her friends nearby.......there is no comfortable place until the deeper movement begins; the pushing and the force that brings birth.

- I think most of you know, by now, that I never write to inflict damage or pain but, sometimes, as in all birth, there is pain. I have found it deeply painful to see what I've had to see over these last two weeks. To not speak to it would be to reinhabit an old life; a way of being learned in childhood--of secrecy, of never owning my own ideas and thoughts because I believed the threats and the attempts to control and I believed that my voice didn't matter........we grow up and, if we're lucky and someone helps us, we learn that these things aren't true.

- We have to set an example of peaceful reconciliation and inclusivity; a true and generous inclusion that knows that all birthing women matter and knows, as well, that Midwifery is a wise, old woman---a Crone now---who can embrace paradox, hold the tension between conflicting and overlapping needs and become a true force for good for women and families.

(end quotes)

Michelle's words, so poetic and enfolding visions of birth, touched me deeply. Not only because she quotes me and knows of my own experiences in my pulled down piece ("Midwifery Education,") but because she, a "seeing" woman, recognizes nuances I had never considered.

As a woman who was abused as a child, I absolutely see the Truth in what she says regarding our speaking out about the need for more education in midwifery is exactly parallel to a child spilling the beans about incest; disgust, disbelief, anger, manipulation, teasing, threatening and withdrawing of love, support or even acknowledgement. How is midwifery supposed to survive at all if the participant midwives can't even speak with kindness to one another? What happened to human decency? My initial responses, even, mimicked that of a hurt child... apologetic, thinking I was wrong, embarrassed that I'd opened my mouth and feeling shame that I betrayed The Sisterhood.

But, I shook my head and cleared the angry fog out of my brain and saw that I hadn't done anything wrong! I spoke my Truth. MY. MINE.

Listening to those that critiqued my removed piece was a really interesting study in human communication. I see where some people could feel anger and frustration at what I wrote and that I was "dissing" midwifery altogether. I'm hoping my WHO piece puts that to rest. I do acknowledge I probably could have written a (somewhat) less inflamed post, but I wrote what I felt/feel. And, after all, it is a blog - MY blog - and my opinion isn't the be-all-and-end-all to midwives, students or apprentices. Sometimes, my writing provokes. I'm certainly not trying to provoke violence (of which I feel some people danced quite near to), but am wanting to provoke thought, wonder, curiosity and solutions. What the heck is so wrong with that?

I'm not wanting to sit here and defend myself (again), but it's all tied in together. This educational component and the subsequent disturbance of the mention of such education reflects on ALL of midwifery - those that agree and those that don't.

What I am coming to realize is that maybe it isn't just education that midwifery needs, but some serious classes in Ethics and Professionalism.

More on that in a soon-to-be post.

Thursday
Feb072008

11 Myths About...

... Top 10 Childbirth Myths.

(The Owner of the above site initially made her blog private after I posted this. She has since opened it back up to the public without an iota of an acknowledgement that she re-considered anything the others or I have said to her. I encourage going there and commenting if you have something to say to her.)

1. When citing research, anything that is in print or on the web is true and I can use them as citations.

FALSE! Citing magazines such as Compleat Mother or websites such as Mothering.com and Pregnancy.about.com is not only inappropriate, it makes you look foolish. Compleat Mother is a magazine for the fringes (and I have been published in there more than once, so I can say that lovingly) and most of the content is written by mothers, not researchers.

You write:

“And before a single person comes and says "but but"...don't comment unless you have medical evidence, as in published research, to back it up. Period. All other comments can and will be deleted.”

Yet your own “citations” are anecdotal and un-researched.

Just because it is in print or on a website doesn’t make it true. Even if I write it.

2. Before Cesareans, women only died of diseases.

Can I just say, “HOW THE HELL CAN YOU SAY THAT?!?” You, Christy, need to read some midwifery texts from the 1600-1900’s. You only need look at our world today to know that this is so absurd it leaves me blinking at your ignorance.

From UNICEF's site (since we are using websites as a source):

”The complications of pregnancy and childbirth are a leading cause of death and disability among women of reproductive age in developing countries; more than 500,000 women die each year from maternal causes. And for every woman who dies, approximately 20 more suffer injuries, infection and disabilities in pregnancy or childbirth.

"The most common fatal complication is post-partum haemorrhage. Sepsis, complications of unsafe abortion, prolonged or obstructed labour, and the hypertensive disorders of pregnancy, especially eclampsia, claim further lives."

Making sweeping assumptions is extremely dangerous to the women reading your post.

3. “Again, unless you've been wearing a corset since puberty, or unless you have some bone deformation that effected (sic) your pelvis, or you were in an accident that effected (sic) your pelvis...this is not going to happen. Period. Less than 2% of women truly cannot birth their babies, and it has nothing to do with weight...it has to do with one of the reasons mentioned above.”

Sitting dumbfounded

You have got to be kidding, right?

This site discusses the rates of death and damage to babies born via planned breech birth compared to planned cesarean births. Mal-presentation is a serious and not unusual reason for a baby to die in utero around the world.

There are babies that don’t fit! Women eat enormous amounts of calories in this and other “developed” countries. Our meat and dairy supply harbors growth hormones that can affect a baby’s final weight. Women in our country are FAT (myself included) and they can grow some really big babies that can – and do – get stuck. Ask the multitudes of mothers who have experienced a shoulder dystocia... even women who did not have epidurals and were not on their backs.

(And of course I know the reasons for most shoulder dystocias don’t occur in the home – vacuum, forceps, immobility – but that doesn’t mean they don’t happen in homebirths. Personally, I’ve had 4 serious shoulder dystocia babies in appropriately-nourished mothers who grew huge babies – and one of my own [I was over-nourished]. We aren’t debating that there can be precipitating causes for a woman’s inability to push a baby out, but discussing that sometimes there are causes that can’t be prevented!)

What about women birthing babies who are persistent oblique lies? Transverse? Babies with spina bifida? Babies with hydrocephalus? Triplets? Babies with a really short cord? Babies with cords wrapped incredibly tight around their necks? Moms with a placenta previa? Moms whose babies are so post-dates the head no longer molds? Babies with a posterior face presentation? Some babies in a military position? Plenty of posterior babies find themselves in a too-tight place and need to be birthed via surgery.

Your thoughts do a great deal of damage to women who had valid reasons for having a cesarean. If I were a potential client reading your blog, I would stay far, far away from you because of your inflexible and unrealistic attitude towards the real-world possibilities in birth. You certainly don’t have to be paranoid when working in birth, but an understanding of the potential is crucial. How else can you be an appropriate lifeguard if you don’t recognize a drowning swimmer?

4. It’s okay that the baby’s cord is around the neck, you can always deliver your baby vaginally. “Babies will have cords long enough to facilitate a vaginal delivery. It's extremely rare that a baby will have a cord too short to do so. And really, there is NO way of knowing before you've gone through NATURAL labor.”

This quote illuminates one of the main issues in your entire post. You sound so sure of yourself, speaking in absolutes. “Babies will have cords long enough....” Yet, in the next sentence you say, “It’s extremely rare that a baby will have a cord too short to do so.” What is it? The cord is always long enough? Or rarely the baby won’t.

You say, “... there is NO way of knowing before you’ve gone through NATURAL labor.” How can you look a mother who’s lost her baby from a cord accident in the eye after thinking this? While you may not know anyone who’s had a baby die from a cord accident, you will one day. You’ll know several.

This myth you harbour is so wrong, so damaging to the truth about cords, it’s hard to understand what kind of midwifery you are studying. Are you reading midwifery texts?

From this Yale Medical School site :

“IUFD due to umbilical cord complications. The most common cause of IUFD in the third trimester is due to umbilical cord accidents. Carey and Rayburn reported that over a five year period in their institution a single nuchal cord was observed in 23.6 percent of all deliveries, both live and stillborn, and multiple nuchal cords were found in 3.7 percent of the stillborns. In another study Sornes determined an incidence of umbilical cord knots to be 1 percent, and a knot associated mortality rate of 2.7 percent. This was in contrast to the 0.48 percent rate of mortality in unknotted population. However, mere presence of a knot does not predict death. If the knot is loose and fetal circulation is maintained the fetus can survive, but if the knot is tightened, then there can be constriction of the blood vessels and fetal circulation can not be maintained. Furthermore, decreased Wharton’s jelly in certain areas of the cord, most notably the fetal and placental insertions, can result in occlusion of fetal blood flow if the vessels are twisted sufficiently.”

5. It’s okay that your water has been broken for days – and even weeks – if you keep everything out of the vagina, nothing bad will happen. Oh, and if you do mysteriously get an infection, you’ll get a fever to let you know.

FALSE. Reminding you, I went 7 days with my membranes ruptured with my third, but I had a doppler, went in to be checked by CNMs and had an NST and was meticulous with my vaginal care, but a woman in my care would not, in almost any circumstance I can think of, be encouraged to sit idly by waiting for labor to begin. Even I didn’t just sit there. I was nursing a toddler, did castor oil twice... even tried the cohoshes (with my German midwife there listening to the baby), all to no avail. I did eventually go into labor on my own, helped by my nursing daughter.

If a client of mine had ROM (release/rupture of membranes), not only would she be doing the infection precautions (nothing in the vagina, no baths [in general, these are fine with ROM in labor, but sitting in one’s dirty water, as far as I’m concerned, isn’t optimal for the baby], no tampons, taking her temperature every 4 hours, plenty of Vitamin C), but I would be at her house every few hours to listen to the baby, doing make-shift NSTs to see how the baby was doing. I might send her in for an NST/BPP. I’d have her do kick counts twice (or more) a day. I’d have her drinking a gallon of water a day. She'd be taking a goodly dose of Vitamin C. She’d also be pro-active getting things moving after 12 hours of ROM with no contractions. I’d offer her IV antibiotics after 18 hours, so would be there every 4-6 hours after that to give the antibiotics. I’d be hard pressed to go past 24 hours without considering Plan B.

Too much? The atmosphere isn’t one of drama or fear, but a healthy dose of considering the baby’s health and welfare. The visits are pleasant and light-hearted; my blending in with the family and gentle nudges to move into labor.

It is not true that infection is always heralded by a fever.

From The Green Journal:

“Among 6294 women who delivered in 1996, 189 (3%) had hospital discharge diagnoses of maternal chorioamnionitis. Fever was identified in 86, tender uterus in seven of 133, maternal tachycardia in 63, fetal tachycardia in 67 of 133, and foul-smelling AF in 10 of 136. Among 53 cases without fever, 30 had at least one clinical finding consistent with chorioamnionitis, and 72 of 86 cases with fever had at least one additional clinical finding consistent with chorioamnionitis. A total of 19 cases had no recorded objective evidence for clinical chorioamnionitis, and 11 of those had histologic (diagnosed via pathology) chorioamnionitis.”

Read here for even more information.

And one more note about prolonged ROM without labor. If a woman is GBS positive, has a herpes outbreak while waiting, has another sort of infection that hasn’t been diagnosed, she may have NO symptoms whatsoever, yet be infecting her baby as she waits for labor to begin.

From EMedicine:

“Because only 0.5-1% of mothers who carry GBS develop signs and symptoms of disease, clinical diagnosis of GBS infection can be problematic.

"In pregnant women, GBS is a cause of cystitis, amnionitis, endometritis, and stillbirth. Occasionally, GBS has caused endocarditis and meningitis in pregnant women, while, in postpartum women, GBS has been identified as a cause of urinary tract infections (UTIs) and pelvic abscesses.”

And while the majority of my clients choose not to be tested and plenty of homebirthing women also choose not to be tested, it is a consideration when awaiting labor with ROM. GBS infection can have no symptoms in the mother while infecting the baby. Something to remember.

6. ACOG encourages VBACs and women shouldn’t worry about the risk of uterine rupture.

ACOG says:

“Most women with one previous cesarean delivery with a low-transverse incision are candidates for VBAC and should be counseled about VBAC and offered a trial of labor.”

and

“Because uterine rupture may be catastrophic, VBAC should be attempted in institutions equipped to respond to emergencies with physicians immediately available to provide emergency care.”

and

“After thorough counseling that weighs the individual benefits and risks of VBAC, the ultimate decision to attempt this procedure or undergo a repeat cesarean delivery should be made by the patient and her physician. This discussion should be documented in the medical record.”

I’d hardly call that “encouragement.” In fact, it sounds incredibly discouraging to me and it is because of the second paragraph that too many hospitals aren’t even permitting VBACs anymore.

Christy says, “So then why do women believe that the *LESS THAN 1%* risk is too high?”

Perhaps because – for them – that risk is too high! Women are permitted to make their own conclusions and while it is true that enough OBs discourage/ban VBACs that it’s annoying as hell, it is also true that many women choosing a repeat cesarean have made that choice with their own research and thought process. Discounting women’s choices and saying that they shouldn’t concern themselves about a rupture is irresponsible and dangerous.

An important reminder: When that “less than 1%” is YOU, it is 100% for you. That the number exists means it happens.

7. “When you induce at 38 weeks, you're essentially inducing a 36 week baby. Period. And let's not forget that the BABY is the one that initiates labor. The baby's lungs release a hormone called Surfactant, and this hormone begins the labor process. When you induce, you're trying to induce a baby who's not ready to be born.”

I highly suggest you go back and learn how to determine gestational age. I don’t know where you learned that a 38 week pregnancy makes for a 36 week baby, but whoever gave you that information is WRONG. For crying out loud, Christy, this is BASIC birthing information. Your emphasis (“Period.”) doesn’t make it true.

Period.

The baby MAY initiate labor... or at least be one of the factors in starting it. There are still so many unknowns that it would be complete arrogance to state that one variable is the trigger.

As others pointed out, if surfactant were THE domino that started labor, why are babies born prematurely without it? How come some full-term babies are born without it?

Here it says:

“In full-term babies with unexplained progressive respiratory distress from birth and progress of radiological changes, both AD and SPBD should be considered. (Acinar Dysplasia and Surfactant Protein B Deficiency)

“Pulmonary surfactant dysfunction (inactivation, deficiency) has been implicated in term neonates with respiratory failure.”

8. When a woman has an epidural, she is completely immobile and has to lay on her back the entire rest of her labor.

Hmm. Have you not seen women be able to sit on birth balls, in rocking chairs or kneel in bed with (walking) epidurals? Did you know that sitting isn’t laying on the vena cava? Have you not seen women with epidurals have to rotate from side to side to get the medication to the unaffected side? Do you not see women bend their knees?

If you are being emphatic, be truthful and clear. Don’t make sweeping generalizations that aren’t true. You make it sound like a woman is all but in a coma with an epidural. Not so at all.

There are many other exaggerations in your number 7 (epidurals causing BP issues that cause cesareans [typically, they slam fluids and it’s resolved many more times than a cesarean is necessary], epidural births often end in the need for a vacuum extraction or the use of forceps [untrue! SOMETIMES, not often]) - , too, but this is long enough already.

9. Amniotic Fluid is the baby’s urine.

No, it’s not!

"Where does amniotic fluid come from?

"Early in the pregnancy, the placenta produces amniotic fluid. Later on, about the fourth month or so, the baby's kidneys start to work, and then the amniotic fluid is made there. Although the kidneys ultimately are responsible for filtering waste products out of the blood and making urine, amniotic fluid is not urine as we think of it. The majority of the baby's waste products actually are transported through the placenta to the mother's circulation and are then filtered by her kidneys. This cycle repeats on a regular basis as the baby swallows fluid and releases it through her urinary system, and so on."

From GYNOB.com:

"By the beginning of the second trimester there are 50 cc of fluid in the amniotic sac, and this fluid isn't much different from the baby's plasma, indicating an origin from secretions through the umbilical cord, membrane coverings of the placenta, and even the baby's skin. By the 36th week there is usually around a liter of amniotic fluid, but by this time it is made up for the most part from fetal urine. The turnover of fluid is fairly rapid, with a build up from urine and a reabsorption from fetal swallowing being important dynamics in the amniotic fluid picture from hour to hour. Since the baby's kidneys mature over the gestation, the amniotic fluid is more fetal urine-like later than it is when the kidneys are less mature. "

You also speak about low fluid volume and that in 98% of cases, drinking a gallon of water will remedy the issue. Only the misunderstanding of the placenta’s role in amniotic fluid could bring someone to say that.

Amniotic fluid is NOT only a mother’s fluid intake! Mind you, I have women hydrate before ever doing an AFI or BPP because it can make a difference (and research does say it can significantly elevate fluid levels), but if a placenta is deteriorating, gallons of water ain’t goin’ to make a hootie bit of difference. Where did you pull “98% of cases” from? Where did you obtain the protocols for low amniotic fluid from?

Here read what the Journal of Family Practice considers appropriate protocols.

While hydrating is one of the recommendations, it also states the repeat ultrasound should be within 4-6 hours, not 24 hours as you stated.

And if a woman has a(true)n amniotic fluid volume under 5, she best be discussing what she’s going to do immediately, not going home to research and deciding what to do. INFORMED CONSENT (as you holler) includes knowing about cord compression, placental insufficiency, fetal wasting, possible fetal distress in labor as well as the risks that come with induction, including the risk of cesarean being doubled. All of these things should be a part of the discussion. Not just the scary stuff about induction; not just the scary stuff about not inducing.

You also mention non-medical induction as an option for induction if it’s called for, but only speak about a Foley Catheter insertion. Foley’s don’t always fit/work. What then? What other non-medicinal ways do you mean? Castor oil? Nipple stimulation? Each of those has their own risks associated with them, too… you know that, right? Even the Foley isn’t without its own set of risks including infection, possible ROM, maternal discomfort, etc. No method of induction, natural or artificial, is without risks. This is yet another aspect of informed consent that’s crucial in a midwifery practice.

Lastly on this Myth, you asked what the woman was doing having an ultrasound for in the first place. Perhaps the baby has slowed down and she wants to know how s/he is fairing in there. Perhaps she is measuring small or large for dates and more information is needed/wanted. Perhaps, if you would excuse me for saying so, but perhaps it isn’t all horrors when a woman goes beyond (insert your arbitrary point of comfort here) weeks and taking a peek at the baby can offer a lot of reassurance that things are clicking along fine and dandy.

Perhaps acknowledging statistical evidence might be in order, preparing a woman for the BPP with proper counseling before she goes in (as I do and have shared here on this site before), coaching her on the typical remarks she might hear, and being available to her should they tell her it is crucial to be induced now. Perhaps not demonizing ultrasounds is a dandy idea considering the vast amounts of information one can learn from them – when they are used judiciously and professionally.

One of my favorite lines: The judicious use of technology is fantastic. It’s the indiscriminate use that is abhorrent. (“Can we all say, ‘Amen!’”)

10. “Does anyone actually know what HAPPENS when membranes are stripped? The care provider inserts his/her fingers INTO the cervix, hooks the finger in between the cervix and the amniotic sac (if even possible...most women that request this aren't [sic] barely a fingertip dilated)”

Yes, many, if not most, women know what happens when the membranes are stripped/swept – IF their provider gives them that information or IF the woman is told the truth when she asks what it is.

I’m not sure where you heard that “most” women are “barely a fingertip dilated,” but in my 25 years and in all the places from hospitals, birth centers and home, care providers simply wouldn’t even try to strip someone without the cervix being at least 2-3 cm. And, while we are on that sentence, I have rarely heard a woman ask to be stripped. It is almost always something that is brought up by the provider because of a post-dates pregnancy and concerns about a medical induction are looming. You also say “it is not uncommon” for the membranes to rupture with stripping. Not true! It happens, yes. But, common? No, it isn’t.

I should insert another Myth here, but you’ve blithely included it in this one, so I’ll call it…

  • Myth 10.5 The baby will come out when s/he is ready.

Not always. Some babies will cook inside until they die. It isn’t uncommon for women who need help getting pregnant to need help getting un-pregnant. Women with insulin resistance issues, seriously obese women, women with PCOS/Syndrome X or women with infertility issues that are hormonal in origin all can need help with starting their labors. Of course, it isn’t every woman, but enough to raise the eyebrows of any care provider when a pregnancy is plodding on and on. And on.

For some, it’s far better to strip membranes, use EPO, do nipple stimulation, herbs, sex, castor oil, herbs, etc. instead of pitocin. Other women just want to cut to the chase and induce with pit right out. Again, informed consent is vital.

MOST babies do perfectly fine at or after 42 weeks, but it is a statistical fact that babies born after 42 weeks have a higher mortality rate.

From this midwifery site:

It is undeniable that the rate of stillbirths and neonatal deaths does rise as pregnancy becomes more and more prolonged. However, many of these deaths are due to congenital abnormalities, or occur in babies with intra-uterine growth restriction.”

I would note that it wouldn’t be unheard of for a woman wanting to out-wait a post-dates pregnancy that she might not have had an ultrasound in the first place or, if she has, it might have been so early she wouldn’t know if there were anomalies. And, truly post-term babies don’t keep gaining weight; they actually start losing fat and weight, possibly putting them in the IUGR classification.

What’s nice in this culture is it doesn’t have to be an all-or-nothing proposition. It doesn’t have to be, “I’m just going to sit here and wait until the baby comes out even if hell freezes over first,” nor does it have to be, “Give me a failed induction with a hefty serving of a cesarean on top.” We can actually utilize the technology we have in a positive way, use it to our benefit, to gather information that aids in our own informed consent. We canNOT always depend on others to tell us everything we need to know. Nor can we just “know everything’s alright because I know it is.” We have a real responsibility to our own care and our baby’s lives to find the truth in the matter. Use whatever means are available to come to the conclusion that works for you. Have your midwife do a makeshift NST. Make sure you are doing meticulous kick counts every day. Pay attention if the baby slows down. (Term babies do NOT slow down. The movements get “tighter,” but the baby does not stop moving. If your baby stops moving, GET HELP!) Whatever you choose to do, don’t just stick your head in the sand.

Whew. One more. Well, one and a half.

11. Women who “claim” they pushed for hours really weren’t completely dilated and were forced to push before they were ready. Or they were in bed. Or had an epidural. Or were induced (which I have zero idea why this even matters).

Uh, nope. Some women, even when not medicated, are upright, even squatting, still push for hours and need a cesarean in order to get the baby out healthy and alive. In the last two years, one in the last 6 weeks! I’ve had two women who pushed for several hours. One had forceps to help the baby out (because there wasn’t an operating room available) and the other had a cesarean for a baby in the military position. The babies did well, but they don’t stay well with endless hours of pushing.

True, many women in the hospital are medicated and in bed. True, pushing in that position sucks for rotating a baby out of the pelvis. I don’t dispute that at all. What I take umbrage with is the word “claim” more than anything else. Like a woman is lying to you or everyone else. What do you know? Do you have her records in your hand? Were you there? Were you the provider who was in charge of making the decision to deliver a happy baby or keep pushing needlessly until the baby wigs out and needs to come out really fast?

If nothing changes, then nothing changes.

If the woman has an epidural and is in bed and has been pushing for a long time (use your own judgment about what a “long time” is) and there’s no forward movement, what good will more pushing do if she still has an epidural and is still in bed?

Something needs to change, yes? Let the epidural wear off if she’s game for that. Get her in different positions. (Hospitals won’t feed her, but in a homebirth we would.) Even let her rest some as long as the baby is being watched closely and all is well. But, as we know from countries without care like us, babies die impacted in their mothers’ bodies and ours can, too... if we just wait and wait and wait.

You say, “Your body WILL labor the baby down. Sometimes women are at 10cm for a few hours before feeling that urge. THAT'S OKAY!”

I’ve been doing this a long time and I haven’t ever seen, or heard of anyone in real life world, at 10cm for “a few hours” before the urge to push came along. Awhile, yes, but a few hours? Why would the body work that way? Unless there wasn’t appropriate pressure on the cervix, the normal course is dilation, then pushing. And, if someone is waiting a few hours, I’m hoping someone is listening to the baby to make sure s/he is doing well with the lull. Labors can peter out from maternal exhaustion and when mom is exhausted, babies can be (and eventually are) affected.

I agree that pushing immediately upon announcing a woman is 10cm is not the way to go – unless the baby needs to come out sooner than later (there are always caveats!). In fact, if people keep their hands out of the vagina and off the cervix, the mom will begin pushing when she is ready. But, if there is a long lull after wonderful strong contractions, someone might want to check and see what is happening... is the baby in a good position to put pressure on the cervix? Is there a hand there? Or is the lull just the normal course of events. This lull is different than one where a labor just seems to wind down – runs out of steam. That is the more ominous labor... exhaustion, malpresentation are two major reasons. And a posterior baby. Another common reason.

Some women need to push harder than others – when the baby is having a hard time and needs to get out or when the baby is a goodly size – these women in particular might need to do some of that Val Salva pushing to get a baby through the pelvis sooner or easier.

But the truth is, the body will not always labor the baby down. And midwives and doctors have skills in assessment for a reason and that it to use them – when appropriate!

  • 11.5 Women just don’t know that they didn’t need that cesarean. It’s my duty to make them feel like crap about their birth experience, not allow them to discover on their own if a cesarean was warranted. It’s important to discount a woman’s birth story even if I wasn’t there, don’t have her records, don’t know HER truth.

I think of all the things in this post that irks me the most, it is this belief.

Recently, I made judgments on another woman’s birth story and was quickly slapped hard to remind me to allow her to have her experience... keep it tender inside. I pulled the post (and want to thank the commenter that spanked me hard over it, too!) and shook my head to clear the fog so I could remind myself that women see what they need to see in their own time. Yes, women reading your blog were certainly led there, but hearing the snide implication that they were stupid for not changing their own births is just mean.

I encourage you to watch your tone when speaking about choices other women make. Intonation is hard to interpret in writing oftentimes. Some women agonize over their need for a cesarean (in fact, I’d say most women are deeply affected by the experience) and it’s vital for a midwife to BE where a woman is so she feels safe discussing the issue with you. She needs to know she won’t be judged, but that you (her midwife) will be empathetic and available should she need to know more information. Making a woman feel stupid is cruel.

Cases in point (emphasis mine):

“So, my previous posting on "Another Post-Cesarean Maternal Death" brought women out of the woodwork, trying to disprove the *fact* that cesareans are dangerous ( not just according to me - but according to every health organization that's weighed in on it so far ) with their personal stories and anecdotes. Most of them included elements that *led up to* the "need" for a cesarean. So that got me thinking about how many women out there truly believe all of the myths surrounding childbirth. This journal is to have a bit of fun while dispelling the aforementioned myths. : ) And before a single person comes and says "but but"...don't comment unless you have medical evidence, as in published research, to back it up. Period. All other comments can and will be deleted. : ) Have fun!”

(Fun? Have fun? How?)

“Oh, and for those of you who are genuinely wanting to learn....”

“Hmmm...maybe women should start asking their doctors for evidence based research when they tell them that the have to do _____ or _____. ; )

(How is that worth a wink?)

Women, go google (sic)....”

“I fail to see how this argument is even relevant if the person posing this argument would actually take 5 minutes to really think about it.”

“...unless you've been wearing a corset since puberty, or unless you have some bone deformation that effected sic) your pelvis, or you were in an accident that effected (sic) your pelvis...this is not going to happen. Period.”

Women don't understand that the things that you allow into your labor can - and will - often seal the outcome of the delivery.”

If you don't consider trying to force your baby out before he's ready, and possibly causing breathing complications in him...then sure, no big deal.”

“...saying that either their baby was too big, their pelvis was too small, or their body just didn't dilate. When an induction fails, your body does exactly what it's design to do - protect the baby. It didn't end up in a cesarean because the baby was too big, your pelvis was too small, or your body just didn't dilate....it ended in a cesarean because your body was protecting the baby inside who wasn't ready to come out. And then what happened? (you, stupid woman) Baby was cut out of you instead.”

Why do women believe that anesthesia going into their spinal column, integrating into their spinal fluid and through their system will not affect the baby? I really don't get it....”

Does anyone actually know...?”

“The first questions I ask women who claim this....”

So many women believe what they are told, instead of doing the research for themselves. If you'd TRULY like to learn more....”

The information you were trying to impart could have been kindly said. The belittling tone is offensive. I hope, if nothing else, you will take a moment and see if you might, from now on, speak in a gentler tone of voice to the women who might not understand your point of view, but that you want to hear you.

One last point about your number 10.

I find it offensive that you speak about bowel movements when talking about a baby coming out. In fact, many women find it offensive as I have learned over the years. It is a baby coming out, not poop. The sensation is sometimes like a BM, but not always. But thinking about pooping when one’s newborn baby is coming through the pelvis and vagina can cause enormous distress to many women. In fact, it’s a common question from women... wondering if they will have a BM during pushing and their embarrassment in advance about it. It takes some time to help women not be so concerned lest poop come out during pushing. Not every woman loses her concern and embarrassment, either, so mentioning it really isn’t very helpful.

Alllllll this said, I’m sure it looks like I am Ms. Medwife by now, but I say these things, Christy, so you understand the value of debating issues. In order to defend your own information, you must be able to speak from the other side’s viewpoint! If you don’t know ALL the information, how can you give informed consent? (The question always is, “How informed IS informed consent anyway?”)

In your comments section, being snippy about people’s questioning your words is an immature way to react. Folks’ comments are valuable moments in time to think, re-think and re-think again your thoughts and beliefs. It’s a time when you re-group and speak eloquently about what you believe is true.

It’s obvious you care about women, but it’s really important to care, too, about their feelings. And that they get the right information. I hope you’ll look deeply inside and be able to expand your views from narrow to wide open. It’s better for that to happen sooner than later because women you come in contact with in your life can make it a painful growing process.

While this post was directed towards another singular post, the sentiments resonate through too many women’s attitudes about other women’s choices. I’m hoping that those of us who work in birth can sit for a moment and remember that we are speaking to human beings who try hard to do the best they can for their babies (even when we think they are making selfish choices). No one sets out to hurt their child. We can, through our example and anecdotal stories (because really, statistics can be manipulated in a myriad of ways and interpreted differently by different people), illustrate varying ways to think, act, and be.

Be the example you want others to follow. My mantra... and my constant challenge.

Monday
Apr232007

A Piece of My Office

The couch you can see all of is now tie-dyed (I will replace this picture in a day or so with the updated couch), but this is what part of my office looks like. Our Centering Session yesterday (see post below) was held here. Donna sat where the dark blue pillow is and the other women sat on the rest of the couch areas. The guys sat on the floor, as did I. I covered the floor (including that pretty pink rug) with a couple of white blankets because that pink rug sheds like crazy.

I took that flower picture back there. It looks just like an Ovary (Donna pointed that out to me!).

Monday
Apr232007

Front and Centering

Have y'all heard of Centering yet? My apprentice Donna and I started Centering with three of our clients due in the Summer a couple of months ago and I am so loving it!

If you go to the website mentioned above, you will see the program seems to be very oriented towards young women and those who are at risk (socially/medically). What we've done is take the outline and tailored it towards the needs of homebirthing women.

For example, today we talked about getting the home ready for the birth, what the supplies were for, talked about water birth, the birth tub and where to get the supplies. We also talked about GBS testing because two of the women are at that point (one will be in a few more weeks) and went over the two women's diets that turned their diet sheets in tonight.

What I am finding so wonderful about our Centering sessions is it is like a childbirth class, but with prenatals. The women are bonding with each other, talking with each other about different things, asking each other for information and advice and we (Donna and I) are letting the women lead each other and are there to guide and be there for factual information when it is required. It really is a great sight to behold!

Today, we met in my office instead of the classroom because there was a childbirth class going on in the classroom. More intimate, but not bad. The guys and I sat on the floor and the women sat on the couches. I have two couches (I'll put pics up of my office.) and these odd rugs that shed that I got from IKEA, so I threw down a couple of blankets to sit on. We'd also talked about it being Chocolate Day last session, so I brought Chuao Chocolate and passed that around to those that wanted it. (Chuao is THE best chocolate on the planet - hands down!)

For those that teach childbirth classes, you know this issue well. Sometimes you get a class where the guys just don't speak up. You just don't know what is on their minds - what their issues are. This Centering group is like that. I asked one of the more open dads yesterday what I could do to get the dads to talk more, share more... and he thought maybe if they broke off into their own group, they could share by themselves. I'll try that, but hesitate sending them without a chaparone. If Donna is with us next time, I might send her with them. She'd be a great one to bounce ideas off of. I've tried talking to the guys directly, too, but they are just so quiet! They still come, though, so that says something, right? And they are all going to the Birthing From Within/Hypnobirthing classes. I can't help wondering if they would talk more if we were not in a group setting. I know there will be other sessions where the guys yack it up a lot. In fact, my next session has a couple of repeat dads in it and I know they will be active talkers. It doesn't necessarily mean that a dad is unhappy if he doesn't talk either, right?

I'm glad I jumped into Centering. Many midwives have talked about doing it, but haven't quite gotten the plan into motion. I decided and just did it. Donna and I laid out the topics and went for it. I don't have the exact schedule in front of me, but the topics are something like this (and some topics are covered in the same session):

- Body Image
- Food Choices
- Exercise
- Others' Reactions to Pregnancy & Homebirth
- Preparation for Homebirth
- Waterbirth
- Postpartum Care of Mom & Baby
- Breastfeeding
- Integration of Newborn into the Family

And while discussing topics, we discuss the tests/screens that are due for their weeks' gestation, we talk about any concerns that they want to share in public, we do their blood pressures, fundal heights, listen to heart tones all in the same room together. If women want to speak in private, that is no problem at all, but most share right there... yeast issues, sexual issues... everything... right out in the open! It really is wonderful.

When active children are introduced into the mix, I can see issues arising, however. Kids are an integral part of our prenatal visits and Centering isn't the most kid-friendly model of prenatal care that I can see so far. In the Fall Season coming up, there are several toddlers and pre-schoolers coming up, so we'll see how that goes. I really do want and need children to be a part of mom's prenatal care - it helps so much during the birth - so perhaps I need to be more creative during the Centering Sessions to include them more. Talking can be so boring, though.

I just wanted to share a little of what I was doing in our offices that might inspire you all to try something different if you were so inclined. Even of it isn't Centering, per se, maybe gathering women together in a different way could be your project.

And so I keep thinking forward!